Latest related coverage

Martin Tattersall still must tell people they might have only a
few months to live, but these days he puts a new spin on it. The
professor of cancer medicine at the University of Sydney was
frustrated with the guesswork in delivering a prognosis to a
patient with advanced cancer, so he decided to measure the
reliability of doctors' estimates.

The cases of 100 newly diagnosed patients were presented to
cancer specialists who were asked to judge when 10 per cent would
die, when 50 per cent would die and when 90 per cent would die. The
specialists predicted extremely well the average actual survival -
about 10 months. "Then we looked at individuals and we were
bloody hopeless," says Tattersall, who consequently came up with a
new formula.

Take the lifespan a doctor predicts - say, 12 months - then
halve it and double it to arrive at a range of six to 24 months. It
is fair to say, he says, that two-thirds of people will be dead
within that range. But a third will not be, and Tattersall includes
all this as a hopeful caveat when his patient's prognosis is
otherwise dire.

Consider a tidy little package of malignant cells contained
within a clear margin and identified by a screening test before
symptoms become apparent. It can be neatly excised, then reliably
mopped up with radiation or drugs.

But the situation is much messier for at least 15 per cent of
cancer patients in NSW. At diagnosis their cancer is already
advanced, having leaked through the bloodstream and reseeded at
distant points: the brain, liver, lungs or bones.

For those with the relative fortune of being diagnosed with
localised cancer, there is an 83 per cent chance of living at least
five more years. For people diagnosed with spread - or metastatic -
cancer, the chance of living another five years is just 13 per
cent.

And yet, as Tattersall's survey demonstrates, the grimness is
far from uniform. Even in cases deemed incurable, new medicines and
revised surgery approaches may make startling differences.

When Professor Jim Bishop, the chief executive of the Cancer
Institute NSW, began his career, no more than 20 per cent of women
with advanced breast cancer lived five years beyond diagnosis; now
41 per cent do.

Hormone treatments such as tamoxifen suppress
oestrogen-sensitive tumours - the majority of breast cancers
affecting post-menopausal women. Over two decades, the drugs have
transformed even advanced-stage breast cancer into a chronic rather
than lethal disease.

More recently, the drug Herceptin has begun to do the same for
women whose tumours feature the protein HER2, previously a marker
of poorer prognosis.

When people are told they have cancer, Bishop says, their
instinct is to want it gone; people find it hard to accept a tumour
inside them, even if drugs have stopped it growing. "That's a very
difficult emotional state."

But removing a metastasis is a pyrrhic victory if more cancerous
spin-offs are already on the march. Recovering from an operation
may tax the body harder than harbouring a tumour partially tamed by
drugs, and surgery has been generally discouraged after cancer has
spread.

Different nuances are emerging, though. In the case of ovarian
cancer - among the most lethal, because it is normally advanced at
diagnosis - Bishop says there is evidence that debulking secondary
tumours (removing accessible parts of the tumour) improves
survival. With bowel cancer, it is becoming clear that spread may
remain for a long time limited to one or two secondary liver
tumours, and removing these can lengthen life.

A few years ago, Bishop says, the balance of benefit and risk
usually tilted away from surgery in advanced cancer. Now doctors
increasingly ask themselves why they would not take an isolated
lump from a liver or brain - especially since newer, less toxic
chemotherapies mean more patients are healthy enough to come
through surgery.

Professor Ian Olver says it is essential patients with advanced
cancer understand the goal of their treatment. Some assume
aggressive chemotherapy means the doctor hopes to cure them. In
fact, the treatment may be intended to subdue tumours temporarily
to reduce pain or pressure on vital organs.

Conversely, a softly-softly approach goes against every instinct
of the average person suffering his or her worst health emergency.
But using drugs sparingly, only adding another when the cancer
stops responding to the previous one, potentially lengthens the
time it can be held in control.

They are some of the reasons, says Olver, the Cancer Council
Australia chief executive, that cancer treatment decisions should
be ongoing collaborations between doctor and patient, rather than a
one-off information dump. As relationships build, he says, it gets
easier to recommend or discourage treatments. Still, "people do get
very angry at doctors. It's part of treating a disease that has a
lot of ups and downs."

Always confronting is the measurement of life in months, rather
than decades, but Olver says he is inspired by most patients, who
come to terms with prognoses so they can organise their lives -
"take the lump sum rather than the pension, on the most obvious
level, or patch things up with a relative, take a trip they've
always wanted to".

On Tuesday Dr David Dalley spent six hours in multidisciplinary
cancer team meetings. The director of medical oncology at St
Vincent's Hospital joined a succession of case conferences that
nutted out individuals' treatment plans with radiologists,
surgeons, nurses and social workers. The rationale is that debate
from multiple perspectives yields a better solution than the single
doctor's specialty.

In head and neck cancers, where surgery can be particularly
mutilating, Dalley says such meetings have "helped a lot of
patients, saved them from going under the knife and having their
larynx taken out". These get-togethers also are forums for
troubling questions, such as whether to recommend chemotherapy even
though it may only boost survival chances by 2 per cent.

Sally Crossing, the chairwoman of the advocacy group Cancer
Voices NSW, says: "Patients should be allowed to participate
and hear what's being said about them." It could benefit patients
psychologically by assuring them their cases had been considered
from all angles. "Let's face it: you are the one with the greatest
interest in this. Even if this does not work out, at least you know
the options were covered."

Those options are widening every year. In the case of chronic
myeloid leukaemia, it is now possible not only to test for the
absence of cancer cells, but also to poll DNA in bone marrow for
changes that might indicate the presence of otherwise undetectable
cancer. For other cancer types, genetic signatures might also be
developed for what doctors call a "pathological complete response"
- in other words, a cure.

Cure has been a pariah word in cancer medicine. Remission has
been considered the more appropriate concept, as more people lived
apparently free from disease that no one could guarantee would not
return.

But Bishop believes the time has come to set sights higher. "We
need to get a real handle on whether we can really get rid of
cancer. Our ultimate aim for all these cancers is to cure
them."

Latest related coverage

1226318927582-theage.com.auhttp://www.theage.com.au/news/lifeandstyle/health/roll-of-the-dice-for-the-right-numbers/2008/11/14/1226318927582.htmltheage.com.auSydney Morning Herald2008-11-15Roll of the dice for the right numbersJulie RobothamFor all the anxiety and pessimism, medicine really is getting
better at controlling cancer, writes Julie Robotham.LifeAndStyleHealthLAShttp://www.theage.com.au/news/lifeandstyle/health/fighting-for-a-chance-in-life/2008/11/14/1226318927585.htmlFighting for a chance in lifetext/html-document